How to Write a DSM-5 Diagnosis for Major Depressive Disorder

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), is the cornerstone for mental health professionals in the United States and a globally recognized standard for diagnosing mental health conditions. Accurate diagnosis is the first critical step towards effective treatment and care. For conditions like Major Depressive Disorder (MDD), a precise DSM-5 diagnosis is essential for guiding appropriate interventions and support. This article provides a comprehensive guide on How To Write A Dsm-5 Diagnosis For Major Depressive Disorder, ensuring clarity, accuracy, and clinical utility.

Understanding DSM-5 and Major Depressive Disorder

The DSM-5 serves as an authoritative guide that lists and details the diagnostic criteria for hundreds of mental health disorders. It ensures consistency in diagnosis across different clinicians and settings, using a common language for mental health professionals and researchers worldwide. Each diagnosis in the DSM-5 is associated with an International Classification of Diseases (ICD) code, crucial for billing, record-keeping, and epidemiological data collection. The current ICD-10-CM codes offer enhanced specificity compared to previous versions.

Major Depressive Disorder is characterized by persistent sadness and a loss of interest or pleasure in usual activities. It significantly impairs daily functioning and overall well-being. Understanding the specific DSM-5 criteria for MDD is paramount for any clinician tasked with making this diagnosis.

DSM-5 Diagnostic Criteria for Major Depressive Disorder

To accurately diagnose Major Depressive Disorder according to DSM-5, clinicians must adhere to specific criteria. These criteria are designed to ensure a standardized and reliable diagnostic process. Here are the core diagnostic criteria for MDD:

A. Five or More Symptoms: At least five of the following symptoms must have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day: This can be indicated by subjective report (e.g., feeling sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day: (Indicated by subjective account or observation.)
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day: (Observable by others, not merely subjective feelings of restlessness or being slowed down.)
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day: (Either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. Clinically Significant Distress or Impairment: The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. Not Attributable to a Substance or Another Medical Condition: The episode is not attributable to the physiological effects of a substance or another medical condition.

D. Not Better Explained by Schizophrenia Spectrum and Other Psychotic Disorders: The occurrence of the major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders.

E. Never Been a Manic Episode or Hypomanic Episode: There has never been a manic episode or a hypomanic episode.

Specifiers: Once the criteria for MDD are met, specifiers are used to further refine the diagnosis and provide a more detailed clinical picture. Common specifiers for Major Depressive Disorder include:

• Severity: Mild, Moderate, Severe
• Remission: In Partial Remission, In Full Remission
• Psychotic Features: With Psychotic Features (mood-congruent or mood-incongruent)
• Anxious Distress: With Anxious Distress
• Mixed Features: With Mixed Features
• Melancholic Features: With Melancholic Features
• Atypical Features: With Atypical Features
• Catatonia: With Catatonia
• Peripartum Onset: With Peripartum Onset (during pregnancy or in the 4 weeks following delivery)
• Seasonal Pattern: With Seasonal Pattern (applies to the pattern of major depressive episodes)

Steps to Writing a DSM-5 Diagnosis for Major Depressive Disorder

Writing a DSM-5 diagnosis for Major Depressive Disorder involves a systematic approach. Follow these steps to ensure accuracy and completeness:

1. Conduct a Thorough Clinical Interview: Gather detailed information about the patient’s current symptoms, past psychiatric history, medical history, and psychosocial context. Use open-ended questions to allow the patient to describe their experience in their own words, and then use more specific questions to probe for DSM-5 criteria symptoms.
2. Assess for DSM-5 Criteria Symptoms (Criterion A): Systematically evaluate each of the nine symptoms listed under Criterion A for Major Depressive Disorder. Determine if the patient meets the required number of symptoms (five or more) and if at least one of them is depressed mood or loss of interest/pleasure. Assess the duration and frequency of these symptoms (at least a 2-week period and “most of the day, nearly every day”).
3. Evaluate for Clinically Significant Distress or Impairment (Criterion B): Determine if the patient’s symptoms cause significant distress or impairment in their social, occupational, or other important areas of functioning. This is crucial for differentiating clinical depression from normal sadness or transient mood changes.
4. Rule Out Substance Use and Medical Conditions (Criterion C): Ensure that the depressive symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or another medical condition (e.g., hypothyroidism). Obtain a thorough history of substance use and medical conditions, and consider ordering lab tests or medical consultations if necessary.
5. Differentiate from Schizophrenia Spectrum and Other Psychotic Disorders (Criterion D): Confirm that the depressive episode is not better explained by psychotic disorders like schizophrenia or schizoaffective disorder. If psychotic symptoms are present, clarify their relationship to the mood episode. In MDD with psychotic features, psychotic symptoms occur exclusively during a major depressive episode.
6. Confirm Absence of Manic or Hypomanic Episodes (Criterion E): Verify that the patient has never met criteria for a manic or hypomanic episode. A history of mania or hypomania would suggest a bipolar disorder diagnosis instead of MDD.
7. Determine Relevant Specifiers: Once MDD is diagnosed, apply appropriate specifiers to provide a more nuanced diagnosis. Consider severity, remission status, presence of psychotic features, anxious distress, melancholic features, atypical features, catatonia, peripartum onset, and seasonal pattern. Specifiers enhance treatment planning and prognostic understanding.
8. Document the Diagnosis with DSM-5 Code: Assign the correct DSM-5 diagnostic code for Major Depressive Disorder along with any relevant specifiers. For example, Major Depressive Disorder, severe, recurrent episode, with psychotic features would have a specific code that reflects these elements. Always use the most current ICD-10-CM code for billing and documentation.

Example of a DSM-5 Diagnosis for Major Depressive Disorder

Here’s an example of how to write a DSM-5 diagnosis for Major Depressive Disorder:

Diagnosis:

1. Major Depressive Disorder, Recurrent Episode, Severe with Anxious Distress (F33.2, F41.1)

Narrative Summary:

The patient meets DSM-5 criteria for Major Depressive Disorder, characterized by a recurrent presentation and current episode being severe. The patient endorses depressed mood, loss of interest in activities, significant weight loss, insomnia, fatigue, feelings of worthlessness, diminished concentration, and recurrent thoughts of death for the past three months. These symptoms are causing marked distress and impairment in occupational and social functioning. There is no evidence of substance use or medical conditions causing these symptoms, and psychotic disorders have been ruled out. The patient reports a previous major depressive episode two years ago. Additionally, the specifier “with anxious distress” is noted as the patient also presents with significant anxiety symptoms including feeling keyed up, restless, and worried about various matters.

Conclusion

Writing an accurate DSM-5 diagnosis for Major Depressive Disorder is a critical skill for mental health professionals. By thoroughly understanding and applying the DSM-5 diagnostic criteria, including considering relevant specifiers, clinicians can ensure precise diagnoses that guide effective treatment planning and improve patient outcomes. This systematic approach enhances the reliability and validity of diagnoses, contributing to better mental health care for individuals suffering from depression.